Open Arms: Immigration

If you’ve tried to schedule a physical exam with your doctor recently (or worse, tried to establish care with a new doctor) you probably had to wait a while for an appointment. Sometimes months.

If you called your doctor’s office because you had a sinus infection or the flu, chances are you were told that your doctor’s schedule was already full. If you were lucky, you were offered an appointment with another provider in the office but probably you were directed to your nearest urgent care.

That there is a shortage of general practitioners in this country is unlikely surprising. You have experienced it. And, its only going to get worse.

Many more US medical school graduates become specialists than foreign-born doctors in part because specialists are paid up to 45% more than general practitioners. This doesn’t mean that doctors who choose to specialize are greedy. Studying medicine is an expensive investment (except in countries where education is free).

And the cost is not just financial. Becoming a doctor is a lifelong learning commitment to a demanding job in a hostile healthcare system. For some, the costs simply outweigh the benefits. The result is not enough native-born doctors to meet the growing demand for primary care. This gap in care is partially plugged by foreign-born doctors.

Immigrants.

Immigrants make up more than 1/4 of US physicians. They are a major part of the solution to the primary care shortage problem.

After the travel ban was instituted, American Academy of Family Physicians president John Meigs, MD wrote a passionate letter to the president. I was proud to be a member of the AAFP as I read his words. We are writing to express the importance of this nation continuing its historical tradition of welcoming immigration and the talent and energy these individuals bring to this country. The AAFP promotes and advances the work of family physicians from all religions, races, ethnicities and cultures in the United States and around the world.

Dr. Meigs’ words echoed the sentiments of many family physicians. As an organization, we are adamantly opposed to discrimination of all types, including policies that identify or isolate individuals based on their gender, religion, ethnicity, nationality or geographic location.

The conclusion of his letter could have been written about any profession. Fully engaging all talent and expertise in the healthcare community leads to better health outcomes, diversity in medicine and should be encouraged.

Diversity in medicine should be encouraged. In truth, diversity in everything should be encouraged. Immigrants like Albert Einstein (who came to America during the Nazi occupation) and former Secretary of State Madeleine Albright (who immigrated from Czechoslovakia to flee a Communist takeover) bring diversity that makes this country competitive, colorful and vibrant.  Americans love Thai food and Chinese New Year celebrations. We like to grocery shop in Little Italy and buy Guatemalan handbags and Mexican glassware.  We love diversity.

Immigrants also bring beauty to our country.  John Muir, world-famous naturalist and the “Father of Our National Park System,” was an immigrant from Scotland.

That’s correct. An immigrant is largely responsible for the preservation of the beautiful spaces America treasures.

Unless you are a native American, your family immigrated here. Just ask any elementary student. I remember when I was a little girl that I was so proud to live in the country that took in the tired, the hungry and the poor. I believed in the magic of the melting pot.

And, if I hadn’t met and fallen in love with an immigrant, I might not have ever become a doctor.

I didn’t win a coveted spot in an American medical school when I finished college. Competition was fierce. My mentors encouraged me to try again next year. But I had no interest in finding a job in the allied health field to gain experience and make connections like many aspiring medical students. I had bigger plans for my life. I didn’t just want to be a doctor, I wanted to be a mother. I felt a sense of urgency in my career choice. It was now or never.

So, when I was accepted by a prestigious medical school in my future husband Paul’s homeland, we decided to go for it. It was one of the best decisions we ever made.

Almost 2 dozen years later, just after the travel ban was announced, Paul posted a photograph of his family on the anniversary of their immigration. He wrote: Thank you for taking us in America. I am forever faithful and grateful. One of the first comments on this post read “At least you did it legally.”

I was furious. How do you know?  I wanted to write. Perhaps it was based on the known merits of his high-achieving family. Perhaps the assumption was made because of the color of Paul’s skin. The truth is never quite so black or white, though.

Paul’s family came to America when life was becoming increasingly difficult in Communist Poland. There were strikes and long lines for food. There was a constant threat of violence and rumors that it would only get worse.

Paul’s father Piotr dreamed of a better life for his family. His mother Irena struggled with the decision. She didn’t want to leave her big Polish family and worried she might not see them again if she did. She had a sister, though, who already lived in America and offered to help. When Irena’s mother encouraged her to join her homesick sister she finally felt free to go.

A lot of pieces had to fall into place before they could make such a dream happen. First, they had to get passports out of the country, which was not easy. Many people they knew had been repeatedly refused. Piotr believes that they were able to get their passports because of family connections to The Party, issued strictly on the condition that they would return. They had to pretend to be just visiting America.

Next, they had to borrow money from impoverished family members to purchase the small apartment that they were leaving behind. Paul’s family of four shared this apartment with Piotr’s mother. There were 2 small rooms, one for the children and one for the grandmother. Paul’s parents slept on the couch. Piotr worried that his mother would be forced out of the apartment if they didn’t return.

Finally, Irena’s sister had to buy all 4 plane tickets in cash with American dollars. It was the only way to secure a spot on the chartered plane. The tickets were round trip, though they had no intention of returning.

Only 3 people knew of their intention to immigrate – Paul’s parents and Irena’s sister in America. Paul didn’t even know that they were going “to visit” America until the night before they left. It was too risky to tell the children ahead of time, too easy to destroy the carefully laid plans. Paul raced to the playground to tell his friends that he was leaving for America tomorrow. No one believed him.

I can’t imagine how his parents felt, full of hope and fear, when they boarded the plane with just a few treasured belongings. They must have been overjoyed to be given a shot at the American dream.

Paul’s family moved in with Irena’s sister and her family of 5. Eventually, they applied for political asylum. Eight year old Przemyslaw (renamed Paul) started school unable to speak a word of English. (Now he corrects mine.)

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Paul’s Family just before immigrating to America

If Paul’s family had waited much longer, they wouldn’t have been able to leave. Not long after their arrival in America, martial law was put in effect by the communist government. Military vehicles surged onto the streets and the borders were sealed. Phones were disconnected (and later tapped). Mail was censored. School was suspended while teachers were questioned about their loyalty. Those found to be sympathetic to the resistance were fired.  Media, transportation, healthcare, public services and factories were put under military management. Military courts bypassed the normal court system to imprison the opposition.

If I lived with my children in an oppressive, potentially violent society with no guarantee of our next meal, I expect that I would do whatever it took to get my children to safety.

What parent wouldn’t?

Countless parents fled such regimes to the safety of our country, many without the connections and luck that Paul’s family had. These parents now live in fear that the children they thought they had saved could be sent back to a homeland that they don’t remember. Children who were brought to America with hopeful parents looking for a better life. Children like Paul and his sister.

Like many Americans, I am outraged by the threatened deportation of DREAMers. These are the children of undocumented immigrants, many with no memories of their “home” country. Some speak only English and had no idea that they were undocumented until they applied for college.

And they weren’t just granted a free ride here. DACA (Deferred Action for Childhood Arrivals) status isn’t cheap and strict criteria must be met, including a willingness to go to college or serve in our military. Those who meet the rigorous requirements and background checks are given a 2 year deferral, a dream, to stay and earn their citizenship.

I know I am lucky to have been born in this county, yet I believe these young Americans, raised among us, are every bit as American as I am.

So does former President Obama. In speaking of the threat of deportation of DREAMers he said:

What makes us American is not a question of what we look like, or where our names come from, or the way we pray. What makes us American is our fidelity to a set of ideals – that all of us are created equal; that all of us deserve the chance to make of our lives what we will; that all of us share an obligation to stand up, speak out, and secure our most cherished values for the next generation. That’s how America has traveled this far. That’s how, if we keep at it, we will ultimately reach that more perfect union.

Universities agreed, citing DACA beneficiaries as outstanding students whose presence enriched the learning environment for all students. Dozens of CEOs (including Apple, Microsoft, Amazon, Netflix, AT&T, Wells Fargo, Facebook, and Google) also joined the protest. As it turns out, 3/4 of the top 25 Fortune 500 companies have employees who are DACA recipients.

Why are we so eager to deport these young people? Children (and grandchildren) of immigrants were likely raised with stories of deprivation. Like Paul, they were taught to appreciate their chance at the American dream and the importance of living up to the privilege of living here.  Jonas Edward Salk, who developed the polio vaccine, was the grandchild of Eastern European and Russian immigrants. Henry Judah Heimlich (of the Heimlich maneuver) was the grandchild of Hungarian and Russian Jewish immigrants. Sanjay Gupta, American neurosurgeon and media reporter, is the child of Indian immigrants. Imagine if we had never let these families in (or kicked their children out)?

And yet the future is still uncertain for these young undocumented people.

Meanwhile, our country is becoming increasingly hostile. American citizens are harassed as rumors circulate about people rounded up at their work and homes. My friend’s American family carries identification because, despite being citizens, their ethnic appearance has caused them to be questioned. Their children are directed to come straight home after school. People are scared.

This summer my husband and I decided to go to Canada for our annual birthday bike trip. We were driving in New York along the St. Lawrence river when we came to a roadblock.

A heavily armed man in army fatigues stepped up to our truck. Another armed man, pulled by a lunging German Shepherd, walked around the back and peered into our truck bed. Although we had nothing to hide or fear (we were American citizens in America, after all), I felt my heart quicken.

“What is your relationship?” the man who approached our vehicle asked with a smile.

“We’re married,” Paul and I answered in unison.

“Are you American citizens?” he asked.

“Yes,” we both answered together.

He looked through the window into the back seat of the truck which was piled high with our biking gear.

“Born and raised?” he asked.

“Yes,” I answered quickly.

“No,” said Paul.

I swallowed hard. Did it matter? A year ago I wouldn’t have thought so. But a year ago we probably wouldn’t have been asked.

“Are you naturalized?” he asked Paul. Paul nodded.

“Where and what year?” he asked, his smile fading.

“Hartford, Connecticut,” Paul answered. He stumbled on the year.

I held my breath and then blurted, “1977, right?” When Paul didn’t answer right away I continued, “You were eight, I think. What year was that?”

The pause was infinite.

Eventually, border patrol let us go. We were American citizens, after all.

As we drove away, though, I couldn’t help feeling uneasy about the whole exchange. Shouldn’t the interrogation have ended when we confirmed that we were American citizens? Since when did it matter if a person was “born and raised” here? And, what if we were not white? Might we have been detained longer? Asked to show proof? Had our vehicle searched?

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Birthday Bike Trip, Canada 2017

We can’t be lulled into passivity. Even if you are not married to an immigrant, even if your doctor is not a foreigner or foreign-trained, even if you don’t think you even know any immigrants because you live in a homogenous, non-diverse community – make no mistake. You will be impacted by anti-anything-that isn’t-American legislation.

Hopefully the impact will just be a nuisance, like difficulty traveling to another country (or even in your own if you aren’t white or have an accent). Maybe you’ll have to pay more for domestic fruits when there aren’t enough workers to pick it. Maybe you will have to wait a year to schedule a doctor’s appointment. It could be much, much worse though.

When we push away other cultures and and turn our backs on our neighbors we are not just hurting them, we are hurting ourselves. We are creating a deep wound in our society when we speak of building a wall or deporting young adults. When we allow the pardon of a sheriff renowned for racial profiling and violence we are sending a message to Americans (and to the rest of the world) that we accept bigotry and hatred.

When we react to each horrific act of terrorism by blaming an entire population (or dehumanize the perpetrator by labeling him “an animal”) we most definitely are not making America safer. We are furthering a division that, in small and terrifying pockets, may lead to extremism and actually cause terrorism.

I am a primary care doctor in a mostly white, rural community with relatives who arrived on the Mayflower. Yet the impact of anti-immigration and anti-anything-not-American on my own small life can’t be denied. I suspect if you look deep enough, you will discover that the impact on yours can’t be either.

I don’t want to live in a black and white world when I could live in rainbow.

 

 

 

 

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(Could Easily Have Been) Me, Too (and Every Woman I Know)

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16 year old me

I felt the force of the “Me Too” posts last week like a punch in the chest, the volume knocking the wind out of me even as I knew in my heart that the true count was much higher than those courageous enough to speak out publicly. She’s the woman who didn’t smile back when you passed by her this morning, the elderly widow next door living alone with just her sad memories, the timid girl who gently placed the eggs in your shopping bag. She is your sister, your daughter, your grandmother, your best friend.

How do we right a wrong so engrained in our culture? How do we find the courage to demand respect for others, for ourselves? How do we remember to treat all people, even those who anger, annoy or disgust us with kindness? We can never really know the burden people carry, the sorrows burrowed deep in their hearts.

If you are a woman, you expend an exorbitant amount of psychic energy every day on your safety, even if you’re unaware of it. I know this because, despite my lifelong denial that anything truly terrible will ever happen to me (not me, too), I look around before walking into an empty parking lot. I don’t walk alone at night if I can avoid it. I check behind me before going down a long hallway to a public restroom. I even check the back seat of my car sometimes before I get in. Unfortunately a woman’s instinctual caution in public won’t protect her from the people well known to her in private.

Americans have no problem righteously condemning the burka, adorned by women in “backward countries” to shield her husband’s property from wandering eyes. We are much less vocal, though, about speaking up and acknowledging what’s happening in our own country, where three women are killed every day by domestic violence. Every day.

But violence and sexual harassment are only an overt part of the problem. The mistreatment of women is often more insidious. So much so that we often don’t notice it and when we do it’s easy to ignore. It’s not getting paid as much as a male colleague doing the same job. It’s not being hired in the first place out of fear that an internal clock will eventually lead to maternity leave. It’s preventing access to birth control in a society that still blames the pregnant girl alone for the predicament she’s in.

I am hopeful that the intolerance of intolerance that ignited the pussy hat campaign was just a flicker in an outrage inferno. It’s not that hard to publicly object to a man of power openly degrading women, though. It’s much harder in the private arena. Even women are silent about other abused women, even when they are the people they love.

Anne, a young patient of mine, revealed to me once that her mother actually entered the room where molestation (by another family member) was occurring to retrieve something she had forgotten. The mother got what she was looking for and left. She pretended not to see, guarding her heart against what was happening right in front of her. I grieve for Anne, but also for her mother who must have suffered her own trauma long ago.

I think back in shame to my own college years when someone I love dearly confided in me that she was raped. I remember admonishing her for leaving the party with that man in the first place. As if making a bad choice was a good enough reason for her violation. As if it couldn’t have just as easily been me, too.

Most of my women patients with serious mental health issues eventually share with me a dark story that changed the direction of their life, that robbed them of the person they may have become. Often these assaults occurred when they were young, stealing their childhood innocence, shattering trust for a lifetime. These life-changing events can happen so casually. No one is immune.

One weekend when I was in high school and my parents were away, I invited some friends to sleep over. The night began innocently enough. We pretended we were grown-ups living in our own home, making dinner together. Later that evening we wanted to make popcorn and watch a movie, but realized we had no popcorn. We decided to walk to the convenience store. It was a few miles away and we would have to cut through woods and several neighborhoods to get there. But it was a beautiful summer night and we welcomed the adventure.

On our way to the store we heard the thumping of loud music. Of course, we had to investigate. There was an adult party happening in one of the homes on a typically quiet suburban street. Guests spilled out onto the manicured lawn behind a white picket fence. Feeling a little mischievous, we planned to walk right in as if we were guests. Heads held high, looking much more confident than we felt, we opened the gate. Just like that, we were in.

We wandered around the party, sipping drinks and eating food as if we belonged. Soon my friends and I were separated, dispersed in the raucous crowd.

I took my empty plastic cup back to the spiked fruit punch for another refill. A polite young man offered to pour it for me. Soon we were deep in conversation. He was at least ten years older than me and I was flattered by the attention. When he asked my age I lied and told him I was eighteen.

He then asked me if I wanted to see his new car. I declined, repeatedly. After a few more drinks with him, though, I finally relented. He seemed like a nice guy and I was fully confident in my adolescent judgement. Nothing would happen, not me.

He led me out the front door and down a dark side street. I was a little shaky, but figured it was just nerves and the spiked punch. As the noise of the party receded, I began to wonder if he even had a car. I was relieved when he finally stopped in front of a low-riding sports car and opened the door to show me. He jumped inside and motioned me in. I politely declined, my friends were probably looking for me. He was persistent. I didn’t want to be rude and I most definitely didn’t want him to think I was just a dumb kid so I climbed in next to him.

He reached under his seat and pulled out a small case. I felt a fluttering in my chest as he opened it up. When I peaked inside, I was confused by a mass of pipes and tubes and glass containers. I had no idea what I was looking at. He patiently explained the various drug paraphernalia. He was in rehab, he confided. He used to do a lot of drugs but he was clean now. I thought back to all the drinks he had when we were talking by the punch. Don’t people in rehab avoid alcohol? I suddenly wanted to run. I broke out in a cold sweat.

“Let me take you for a ride,” he said. My heart pounded in my ears so loudly that I was afraid he could hear it too.

I stammered excuses. My friends were waiting. I had to be somewhere. We were just stopping by the party but had plans and it was time to go.

He put his key in the engine anyway.

Just then I noticed that the inside door handle on my side was missing. I turned back to him, unable to hide the terror in my eyes. He reached for the lock on his door. I reflexively reached out the window and grabbed my outside door handle, just as the window started to go up, just as the lock snapped down. I pushed hard and to my great relief the door opened. I jumped out. I freed myself just in time. I heard him cursing as I ran from the car back to the party.

For years I was embarrassed about my stupidity that night. I look back now, though, with compassion at my younger self. If I could’ve been so easily lured away, if I couldn’t say no to a stranger, how much harder must it be for women who actually know their abusers?

My life may have been very different because of my insecurity over a stranger’s judgement. I don’t like to think of what might have happened if my instincts didn’t take over. My door handle was missing. His plan was premeditated.

I may not have even survived the attack.

Or, I might have turned inward in my shame and away from the people I imagined that I had disappointed. I might have dropped out of school and abandoned my dream of becoming a doctor. I might have never been a wife or a mother. In a few short minutes, my life might have been ruined.

Over years of caring for patients, the truth about our shared humanity is so clear to me now. The difference between you and your chronically ill neighbor or the homeless person you carefully avoid eye contact with or the crazy cat lady next door is a lot less than it appears. Often the divisive factors arose in a moment in time beyond their control, when they suffered a heartbreak so deep that continuing with life as usual was no longer a possibility.

What did it take for Anne to heal? First, she had to overcome her undeserved shame that what happened to her was somehow her own fault. Was her dress too short? Could she have fought harder? Did she bring this on herself? She then had to get beyond her broken trust to find the courage to ask for help. This is real bravery. She knew that she was waking a sleeping monster that might take years, even a lifetime, to battle. And this was only the internal part of the fight.

Once she asked for help, Anne and I had to work together to figure out how to get it, not an easy task in a healthcare system with many barriers to mental health treatment. We needed perseverance and determination to connect her with the right people (who also took her insurance and didn’t have a 4 month long waiting list). It’s easy to imagine why people give up, some forever.

What can I possibly do with a problem so immense? It’s as simple as paying attention. When I see or hear something that doesn’t feel right, I will speak up. Because when we don’t stand up for our silent sisters, it sends them (and the world) the message that we don’t care. We accept it. We condone it. We are willing to live in a society with depressed mothers, anxious sisters, suicidal teenagers and teachers and daycare providers.

This is not the kind of world any parent would want to raise their daughters in.

This is not the kind of world I want my sons to grow up in.

 

Life and Death: Mothering and Doctoring

Harry and Ethel were always together.  My nurse, who liked to remind me that she began working at the clinic “before you were out of diapers,” couldn’t recall a single time that either of them had ever come to a doctors appointments without the other. “I guess they must really like each other,” she said after confessing that she sometimes made appointments to get away from her husband.

Harry and Ethel were active. They regularly attended ballroom dancing classes (“We’ll be going forever,” Harry joked with me at his last appointment.  “After 50 years, Ethel still hasn’t learned to let me take the lead.”) They were on a bowling team together and golfed in the summer. They traveled to faraway places. (“Harry likes adventures. I’d be fine with the Jersey shore,” Ethel told me once). They never seemed to tire of one another.

As a first year resident, still new at seeing my own patients, Harry and Ethel were two of my easiest. I looked forward to their visits. They only came to the office for check-ups since they were never really sick. They took no medications (except for multivitamins). They never complained.

So, I was surprised when I found out one Monday morning that Harry was admitted to the hospital. I asked around and discovered that he had slipped on the ice and broken a hip. I was relieved, but in hindsight I was also naive.

While a broken bone didn’t seem like a major medical problem to me that first year of residency (bones heal), I’d soon learn that a hip fracture in an elderly person was a very serious condition. I’d learn that there was a 5-8 fold increased risk of death in the first 3 months after a hip fracture. Of the survivors, only 1/2 would ever return to previous function while 20% would require long-term care.

But Harry’s fall was well before I knew any of that.

When I finished rounding on my morning patients, I went to visit Harry. Over the weekend he had an uncomplicated hip surgery so I found him in the General Medicine wing.

I was not surprised to see Ethel at Harry’s side, reading him a newspaper article. I asked Harry which resident was taking care of him and was happy to hear it was a 1st year colleague of mine. “You’re in good hands!” I said, and they both nodded.

In those early hospital days Harry was in good spirits. He couldn’t wait to get out of the hospital so he could take Ethel dancing. “You just wait to see my moves with this new hip,” he told her.

Rehabilitation was difficult, though. Harry wasn’t used to being immobile and certainly didn’t like being dependent on others. He was also in a lot of pain. The medications made him nauseous and sleepy, which caused him to lose weight and be even less cooperative with physical therapy.

As a new resident, I was very busy and didn’t have a chance to check in on him every day. So I was surprised when I snuck in to visit the next week at how pale and thin he looked. Ethel was trying to coax him to eat a treat she had baked for him that morning (“It’s his favorite!”) but Harry would have none of it.

I looked at Ethel, who was trying hard to be an optimistic cheerleader for her husband. Her eyes were puffy, and I was sure she had been crying. Deep furrows in her forehead appeared etched on her face since the last time I saw her. “He has always been a little stubborn,” she said, smiling at Harry.

Harry was uncharacteristically irritable. “Doc, they want me to go to inpatient rehab after this! Can’t I do these exercises on my own?” I looked to Ethel, who was shaking her head.

“You can’t even get up out of this bed without help,” she said to him. “You need to get stronger before you can think about coming home. Just do what the doctors say so we can both get out of here.”

2 days later my colleague told me that Harry had been transferred to intensive care. I was shocked.  I rushed through my lunch and headed down to the ICU to check on him before my afternoon patients.

I quietly knocked and stepped in to the room. Ethel was seated next to Harry, holding his hand and crying softly. Harry was asleep. I could hear his chest rattling from the doorway.

Ethel looked up and tried to smile, relieved at my arrival. There was so much hope in her eyes that I had to look away.

I sat down next to her. “What happened?” I whispered.

“The doctors say he has pneumonia,” she said, sniffling. Again, I was relieved. Pneumonia was very treatable.

“Well, I guess they’ve got him on strong antibiotics. He’ll be better in no time,” I said with more conviction than I felt as I looked from Ethel’s terrified face to Harry, lying motionless with tubes snaking from his body to the wall.

We sat together side by side in silence.  The only sounds in the room were the humming oxygen tank, Harry’s labored breathing and Ethel’s stifled sniffles. I tried not to look at the clock, though I was sure by now my first afternoon patient was probably waiting for me. Finally, I reached over and squeezed Ethel’s frail hand and told her I had to go. She nodded and thanked me for stopping by, but looked quickly away to shield me from her tears.

I would’ve lingered longer if I knew it was the last time I would see Harry. I might have tried to nudge him awake, and whisper in his ear. Harry, it’s me, just checking in on you. Fight harder. Don’t give up. Ethel needs you.

Harry died on an autumn day much too beautiful to die.

I had only been married to Paul for 5 years, and yet Ethel’s loss was unimaginable.

A few days later, on an equally beautiful day, my husband and I took our young sons apple picking. The sun was bright and the air was crisp and cool. It smelled like wet leaves and wood burning.

We parked our car at the farm stand across the street from the orchard. I steered Buster away from the entrance, knowing that apple cider donuts and pumpkin pie would be hard to resist and would defeat our intention to wear him out. Buster had an endless well of energy that caused Paul and I to collapse into bed at night.

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Buster, up in the trees where we often found him.

We crossed a broad field to get to the orchard. Buster scaled up and down trees while we chased after him, passing Digby back and forth between us. Before we knew it we had 2 big bags of apples, much more than our small family really needed. Paul and I were exhausted. Buster seemed even more energized.

I picked Digby up from the tall green grass where I had set him down while I arranged the overflowing apples so they wouldn’t fall out  during the trek back across the bumpy field. Digby was an easy child and would sit quietly wherever he was placed, as if to balance the ever-busy nature of his older brother.

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A rare protest from the usually tolerant Digby.

I left one of the bags on the ground for Paul and hoisted the other one up while swinging Digby back onto my hip with my free arm.

I walked cautiously, not wanting to trip with my arms full.  Suddenly Buster raced past me toward the farm stand. I heard a loud rumbling from my left and looked up to see an eighteen wheeler barreling down the road, much too fast. I opened my mouth to scream at Buster to stop, but nothing came out. He wouldn’t have heard me anyway.

I froze, my mouth wide open, apples in one arm, Digby in the other. My feet stuck to the ground as Buster raced toward the road and the truck flew toward the farm stand. I realized with horror that the truck wouldn’t be able to stop even if the driver saw the small child running right at it. They were going to collide.

Just as Buster reached the road a lanky teenager appeared out of nowhere and scooped him up into her arms. The truck driver whizzed past, oblivious that he had nearly destroyed my world.

Still, I couldn’t move.

The girl walked over to me and set Buster at my feet. I dropped the apples and set Digby back down on the grass. I reached out with trembling hands and pulled Buster close to me, my breath finally returning as his chest met mine. I buried my face in his curls, my heart beating wildly.

I stood up to thank the girl, but she was gone.

Had life always been so fragile and I was just too busy and tired to notice? I thought of all the times I envied the freedom of my childless colleagues. It was hard, this doctoring and mothering thing. But life without it was unthinkable.

As I squeezed Buster tight I vowed I would forever cherish this wild blessing the universe had given back to me.

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Birthday card adaptation of “Where the Wild Things Are,” featuring my wild thing Buster.

It Would Be Unwise

I started writing this post a little over a month ago, inspired by Reverend Jacqueline Lewis of Middle Collegiate Church in New York City.  She was one of two presenters speaking on “Spirituality and Medicine,” a lecture given at a medical conference I attended. I had no idea what to expect, but I was curious.

The first speaker was the renowned writer and Buddhist practitioner Steven Cope. He spoke eloquently about discovering one’s “dharma,” or true calling. Once determined, he urged, dharma should be pursued passionately without concern for the outcome. According to Cope, just the act of doing what we are driven in our hearts to do is rewarding regardless of the outcome. The joy is in the act of doing, even if we fail.

Reverend Lewis waited patiently onstage while Cope spoke, smiling and nodding in agreement. She looked a little nervous as she smoothed down her skirt and straightened her back. She was tall and beautiful, with smooth dark caramel skin, bright red lipstick and jet black braids. When it was finally her turn to speak, she leapt out of her seat.

Her voice was gentle but strong and she spoke with her whole body. Her braids flew around her shoulders as she danced across the stage passionately calling for love of self and others, preaching tolerance and inclusion to the all-white audience. On a large screen she projected slides of her church in action:  feeding the poor, marching at Gay Pride, laying on the floor of a government building to protest yet another black youth shooting.

She challenged us to disrupt the rampant racism in America. She implored us to imagine in our heads and our hearts what a world with no prejudice would be like.

She asked us to remember a time in our lives where we felt othered. A Jewish woman shared a story from her childhood of being pushed down in the mud by a group of boys for “killing Jesus.”  Even among our white crowd, it wasn’t difficult to remember a time of feeling othered – of being left out by not getting picked for a team, for being a girl or a Muslim or a gay man. The raw feelings of humiliation surfaced easily.

Then she asked us to step back and imagine a lifetime of this?  Imagine the pain of feeling ashamed every day.

As she spoke of peace and community, tears streamed down my cheeks. Her words touched me deeply.  I felt an intense connection with her, as if this black woman was my sister.

By the end of her talk, nearly every face shining back at her appeared ready to take up the cause. I know I was. This was weeks before the invasion of Charlottesville. Way back in a time when white America could still pretend that racism was not really a problem anymore.

Then the unthinkable happened. Worse, though, it was tolerated.

Why are we still fighting this demon? Genetically we are all so similar that the the very concept of race could be questioned.

I reached out recently to my black brother-in-law for some insight. He introduced me to a blog (abagond.wordpress.com) with some thought-provoking articles about race. In his blog post “Why whites are blind to their racism” Julian Abagond writes “America was founded on two crimes: taking the land of the red man and bringing the black man in chains to work it. To feel right and good about that whites had to be racist. They had to think of themselves as far better and more human than others.”

Our forefathers convinced themselves of their superiority so that their abhorrent actions would be acceptable. Otherwise, they would be evil. Although slavery no longer exists in America, oppression and racism clearly do. They are a necessary means to keep wealth in the hands of the (mostly white) elite. Blacks (among other minorities) are the others. They just can’t hide the color of their skin.

When we isolate ourselves in our safe white communities from people of other colors, religions, or beliefs we unintentionally propagate this otherness. And what we don’t know is scary.  I live in a homogenous, nearly all-white town. Despite my rational mind, I can’t deny my own fear when I find myself in an all-black neighborhood. Why?

At best we can hide from our racism and deny its very existence in us. I have done this most of my life. Our country knows what can happen at worst, as recently demonstrated. Racism is not new in America, but the current state of affairs in this country has emboldened haters into violent action. But are these just isolated events by extremists? Is racism really pervasive in every day living?

I asked my sister (who is happily married to a black man for nearly 2 decades) if she thought that racism in America was as bad as current events made it seem. Sadly, her answer confirmed what I had hoped in my heart wasn’t true. She told me that her family experienced racism “from the time we get up until the time we go to bed.” Every day.  Her husband concurred. Despite living in an ethnically diverse area, they are constantly vigilant about their personal safety and the safety of their two sons.

In another blog post (“All blacks are racist”) Abagond writes “When your life is shaped by the colour of your skin it is very hard not to see the world in terms of race. In fact, to be race-blind under such circumstances would be unwise.” Would be unwise. While I was warning my sons not to accept rides from strangers, black parents were teaching their sons to be careful about the ever-present danger of white people. To not instill this caution would be unwise given the alarming mortality statistics of black youths (not to mention their disproportionate representation in prisons).

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My sister and her beautiful family (Women’s March, DC)

Charlottesville was a horrific wake up call to me (and to much of the country). I realized that my strongly held beliefs about equality are meaningless if I keep them to myself. This won’t be easy. I strongly dislike confrontation. But I dislike inequality even more and I know it will not go away if we don’t challenge it. Silence is acceptance.

In his 1986 Nobel Peace Prize speech, Holocaust surviver Elie Wiesel said “We must always take sides. Neutrality helps the oppressor, never the victim. Silence encourages the tormentor, never the tormented.” We must always take sides.

Years ago my oldest son Buster attended a “Future Big Brother” class at our local hospital in preparation for the birth of my youngest son. The nurse leading the class handed him a black baby doll so he could practice being gentle. Although he was a wild and spirited boy, he took this training seriously and held the baby close.

The nurse said to him, “This baby is different than yours will be. Do you know why?”

Buster answered, “Because it isn’t real?”

The nurse laughed. “Well, I guess that’s true, but that isn’t what I was thinking.” She waited for him to answer.

After awhile he said, “Because it’s smaller?” The nurse shook her head.

“Because it has no hair?” She shook her head again. He didn’t want to disappoint her, so he kept guessing.

Finally, she said with a smile, “This baby is different than yours will be because it is black.” My son looked down again at the baby. He looked back at her.

His confused look said:  What difference does that make? Skin color was as insignificant as eye or hair color. His cousins were black.

The nurse looked flustered. I beamed.

I wish I could credit good parenting for his reaction but I know Buster’s response was a natural one for a child. Children aren’t born with prejudice. And as they grow up, exposure to different cultures can further protect them against developing it. It’s hard to hate black people if you have family members who are black. It’s hard to dislike Muslims if your best friend is one.

Hate is taught. But love can be taught, too.

Darkness cannot drive out darkness; only light can do that. Hate cannot drive out hate; only love can do that. (Martin Luther King)

So, how does this relate to healthcare?

Racism has to do with everything. It’s not just about hurling nasty words or violent actions. Racism is an insidious and deadly virus that stealthily invades and eats away at society, spreading to every facet of life from housing to healthcare.

I have never written a blog about the disparity in access to healthcare for the black population because I have very little personal experience. It never even occurred to me until I heard Reverend Lewis speak. Nearly all of my patients are white. But if I am being true to my mission to examine the problems in the American healthcare system (such as the lack of access, no insurance, preventable diseases that are not being prevented), I can’t ignore the importance of race.

Poor Americans have the worst health and 1 in 4 blacks are poor (versus 1 in 10 whites). Compared to whites, black people make 60% less money and have twice the rate of unemployment. They are less likely to own their homes or obtain higher education. Poor people also lack access to nutritious foods and are more likely to live in crowded and polluted areas. They lack access to open spaces.  All of these factors are predictors of health.

Even when poor people have insurance, they often can’t afford prescribed medications. Some of my poor patients have missed appointments with me because they couldn’t afford gas to get to there. Poor people can’t afford to miss work and they can’t afford childcare to come to the office after work. Obviously health outcomes are even worse for the uninsured (who are disproportionately black and Hispanic). In fact, there is a 40% increased risk of death for people without insurance. 40%!

Clearly blacks have enormous economic and social disadvantages compared to whites. Add to that the lack of access to healthcare and the result is a sick population.

There is also a negative impact on mental health and self-esteem for black children living in a world whose major institutions are run by whites. Black kids are constantly told in endless subtle and not-so-subtle ways by the entertainment industry and the news (and now by our government) that they are less important, less trustworthy, less deserving. Black is dark, evil and bad. White is pure and good.

Something has to change.

I believe change can happen when we see others as we see ourselves. This isn’t only a mental exercise, though. We have to step out of our comfort zones and embrace our brothers and sisters of different races and religions through our actions. We can intentionally immerse our families in different cultures. We can visit mosques, introduce ourselves to immigrant neighbors, celebrate Jewish holy days and slowly surround ourselves with others until we no longer notice any difference.

In my experience with difficult patients, even those I strongly disagree with, when I truly listen to their stories I can always find some common ground.  Even in the racists. Even in the misogynists. Sometimes I have to try harder to get past the rough exterior they have built up to ward off years of their own anger and shame.  But when I do, there is always some goodness.  I am forced to confront my own judgmental mind, and shift them out of the other category.

 

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I know I’m not unique. We all have capacity for empathy in us, we just need to remember it and sometimes to purposefully seek it out. After all, we have so much more in common with each other than we have differences.

I also know that much of my life I have been guilty of not speaking up. And although I am committing no acts of violence, my silence may be considered permission to those who would. I will try and follow the example of my courageous sister and summon the courage to find my voice. Even if it means confrontation. I carry her words with me as inspiration. “It starts with the people you love. I will always stick up for the side that is right.” And she does.

And so will I.  To not do so would be unwise.

I believe this is a part of my dharma.

 

Sharing Bread

I was driving through a small town in Vermont last week when I passed a man standing in the bright sun on the side of the road. He was holding a cardboard sign above his head. At first glance, I assumed he was protesting something. This was not a typical place for beggars.

As I slowed to round the corner in front of where he stood, I could read his sign clearly. Struggling Father of 3. Will do any work.

I drove past.

When I was a teenager, my class took a field trip to Philadelphia. It was the first time I saw people sleeping on the street. I was shocked and wanted to help. We were told repeatedly not to give them money. In a country that believed that hard work reaped rewards, the implication was obvious – beggars were lazy. These poor people were to blame for their predicament.  They were unworthy of the small change in my pocket. Besides, our chaperones whispered, the money would just be used for drugs and alcohol. It was enough to stop any idealistic heart.

So, when I saw the young man holding up the sign on the side of the road, I was distrustful. Was he asking for work knowing that people would probably just give him money? But then, who would choose to humiliate himself on the corner, begging for work (or money) if he had better options?

Paul was a father of 3. I was a mother of 3. There were times when we struggled.

I didn’t have any work for the young man, but I did have a fresh baked loaf of bread on the seat next to me. I thought that if he really was struggling, even that little bit might help.

My family follows a beautiful Polish tradition of putting out an extra table setting during holidays so that if an unexpected guest arrives they feel welcome to share the meal. Was this young father not like an unexpected guest?

I did a U-turn and headed back toward him.

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I pulled over onto the shoulder where he stood. He practically ran to my car. He didn’t dress like the vagrants I’d seen in the city, the mentally ill tossed like garbage onto the city streets by an overwhelmed society unable to care for them. He wasn’t dirty. His clothes were worn, but not tattered or wrintkled. He wore a white shirt buttoned all the way up to his collar, tucked carefully into his faded khaki pants. His spiked blond hair was neatly trimmed, his eyes bright and earnest.

Before my window was all the way down he blurted out, “Do you have some work for me?” His eyebrows lifted with enthusiasm. He had a beautiful smile, but when he opened his mouth his remaining teeth betrayed his poverty. Many of my poor patients had bad teeth. They couldn’t afford the luxury of dental care.

I shook my head slowly, my lips pressed tightly together, still skeptical of his motivation but hoping I wasn’t a gullible fool. It wasn’t so much a fear of embarrassment but more that I so wanted to trust him, to believe that he wasn’t out there swindling the community, taking advantage of people’s good nature. I wanted to believe in our shared humanity.

He was a parent of 3. I was a parent of 3.

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Paul & Orion

“I don’t have work,” I said quickly, turning my eyes away to escape his desperation. “I do have some fresh bread, though, if you want it.”

I took a deep breath, waiting for rejection. I had refused beggars asking for money in the past, worried I was supporting an addiction, only to be met with disgust. I once offered to buy a sandwich for a man claiming to be hungry. He glared at me and cursed, unable to contain his outrage. It didn’t feel good.

The young father smiled a crooked tooth smile. “Well, that would be nice. Thank you, ma’am,” he said. He took the bread and walked back toward his sign.

Still, I doubted his sincerity. Was he just being polite so I didn’t warn others in this small town not to stop for him? Was he going to throw my bread out as soon as I drove away. Was he silently cursing me for not giving him money?

I pulled back on to the road and did another U-turn, heading home. I glanced back at him in my rear-view mirror.

The young father was kneeling down on his cardboard box, one leg stretched out straight behind him. He clutched the bread to his side, his head bent low to the earth in prayer.

He was actually giving thanks for my small gift.

I cried the rest of the way home. Not graceful, silent, tears-sliding-down-my-cheeks crying but face-grimacing, breath-catching, shoulder-heaving sobs. It’s so easy to give to someone in need. I’m sure that I felt better sharing my bread with him than he did receiving it.

For years I had mindlessly set the extra plate at the table. The seat remained empty. I am grateful for the young father on the side of the road that showed me I am finally ready, eager even, for someone to sit down.

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Mother of 3

Home Birth

I was with a patient when my first contraction hit. I flinched and frowned at my belly. My patient didn’t notice. Flustered, I stumbled through the rest of the exam and then walked briskly back to my office.

I shut the door and called my obstetrician. Her secretary insisted on getting the doctor right away. “I’m fine! It was just a little tightening,” I protested, adding, “She can just call me when she’s done with her patient.” But the line was silent. She had already left to get the doctor.

“Come right over,” my doctor said. I explained that I had patients scheduled all morning. Would it be possible to come at noon? “Come now!” she insisted. The urgency in her voice convinced me to leave immediately, abandoning my next patient already waiting  in the exam room.

I had several more contractions during the drive to my doctor’s office. I was a little worried, but in denial about the very real possibility of going into early labor. When my doctor finished examining me she told me she didn’t want me going back to work. I assured her that I would take the rest of the day off and speak with my office manager about lightening my load the following day.

“I don’t want you working until you see me in the office next week,” she said, her tone leaving no room for negotiation. She advised me to drink a lot of water and to rest in bed until then.

I was astounded. What would I do for a whole week at home? My oldest son was in school, and my youngest was in preschool. I had worked every day since high school, often two jobs. I worked until the very end of my previous two pregnancies. The thought of sitting around for the safety of my baby both excited and frightened me.  I had permission to rest.

The next week I returned to the doctor’s office carrying a notebook where I had dutifully recorded every contraction since my last visit. Every hour had several marks next to it. My obstetrician looked over the pages. “You’re not going back to work this week,” she informed me.

Each week I faithfully returned with my notebook and each week I was told the same thing. Finally, my doctor told me what I had suspected all along. I was not to return to work until it was safe for my baby to be born, which would be another month or so. After initial feeble protests to the doctor (how would my work manage without me?) and silent worries (could we afford this?), I settled in to the idea. Part of me wondered if I would ever want to return to work.

I rested on my deck in the sunshine and watched as spring came alive around me. I reclined on a bench, nestled in cushions with my feet propped up.  The sun warmed my skin.  The trees were a brilliant green. Small plants pushed up through the dark soil around the deck. The stream hummed with the spring snow thaw from the mountain.

Paul set up a small table next to me which was crammed with my entertainment (I was supposed to be on strict bedrest, after all, getting up only to use the bathroom). On it sat my notebook for recording contractions. Next to this was a bird identification book and binoculars. There was a small stack of books I had been wanting to read, a jug of water and some snacks. On my lap was my latest knitting project, a soft green sweater for my baby.

I was not suffering.

Perhaps I rested too well? I went back to work when I was 32 weeks along and, although the contractions increased with the stress of work and the weight I carried, no baby came.

One day, out of the blue, Paul suggested that we have a home birth. While I was confident that I could labor without drugs (having done this twice already), the thought of delivering at home never occurred to me. Was it safe? Was it crazy? What would my mother say? Reflexively, I dismissed the suggestion, citing safety concerns.

But the idea was planted. I found myself thinking about a home birth a lot over the next few days. Each time the idea became more appealing.

I decided to call my obstetrician, who was a trusted colleague. She was a professional. She would talk sense into me. “I very much value your opinion, “ I began, “and if you tell me that the idea is unsafe, I will never mention it again .” I held my breath, waiting for her to question my sanity. After all I was also a professional. I had seen the terrible unexpected things that sometimes happened during “routine” deliveries. The nearest hospital was 25 minutes away. I lived at the end of a dirt road, almost two miles up in the hills. What was I thinking?

“Actually,” she said in a calm and thoughtful voice, “if I was going to have a baby, I would definitely have it at home.” My jaw dropped. The phone line went silent. When I finally found my voice, I thanked her for her opinion and her honesty.

I called Paul. “Let’s do this!” I said, before I could change my mind.

Of course, I did research the safety of home births.   I also had an unofficial back-up obstetrician (in the hospital) in the event of an emergency.  I knew that hospital deliveries, too, were not without risks – mostly related to infections and increased medical intervention (C-sections, instrumentation, and drugs, to name a few).

Paul and I found a midwife in Rutland, Vermont who was willing to travel to our rural New York home for the birth. We were at the very limit of distance she felt safe for a home delivery.  At the time, it was a felony for her to deliver a baby in our home.

We agreed on a plan: we would go to her place for two prenatal visits and one postnatal visit. She would come to our home to inspect everything once before the delivery (to make sure we had everything we needed and that she knew exactly how to find us), the day of the delivery, and the day after delivery to check on me and the baby.

The trip to her home (which also served as her office) was a beautiful drive through the rolling hills of Vermont. It took over an hour and a half. I felt increasingly anxious the further we drove. She seemed perfect, but was she just too far away? Clearly we would need to give a lot of warning for her to make it to our house in time.

Like us, her home was tucked deep in the woods. She greeted us at the door with a big smile. We removed our shoes, walked up the wooden staircase to her loft office and settled on to a big comfortable couch as she explained how it would all work. She was bright and confident. She had delivered hundreds of babies at home. She would be honored to bring our baby into the world.

We left her house with a list of things we needed to have ready for our home inspection. Some items seemed logical, like plastic sheets to protect the mattress. Other things on the list I had not heard of or couldn’t imagine their use.

It was like a scavenger hunt.  Paul and I went from one store to the next with our list in hand, collecting items. We tucked them in to a storage bin for easy future access. It was clear that this birth would be an entirely different experience from my two prior sterile hospital deliveries.

As I approached my due date, my previously “early delivery risk” baby had become rather comfortable. My due date came and went. My belly grew bigger and bigger. In desperation I tried all sorts of things that I had read might possibly trigger labor. I hiked in the woods and bounced on a four wheeler around the yard.

Riding on a Four Wheeler, past due date

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One night I came home from work to a quiet house. When I asked Paul where everyone was, he told me that he had arranged for the boys to stay over at our friends’ home for the evening because the baby was coming tomorrow.

I protested. It was a school night. I wasn’t in active labor. I didn’t want to take advantage of our friends, knowing we would need them when the time really did come.

Paul insisted. The baby was coming tomorrow.

I awoke the next morning at dawn with mild contractions. I smiled to myself and squeezed Paul’s hand before falling back into a light sleep. After an hour or so, I sat up. My baby was coming today! I wanted to enjoy every minute of it.

It was the most beautiful September day. There was a slight chill in the air but the sun was brilliant and the sky was a deep, cloudless blue.

After breakfast, I threw a jacket on top of my nightgown and pulled winter boots over my swollen feet. I waddled up the hill to pick wildflowers for me and my baby, stopping every few feet to catch my breath. Each time I bent my bulking frame over, I wondered if I would be able to put myself upright again.

On my way back to the house, the contractions became a little more intense. I sat on the bench swing that Paul had hung last summer between two paper birch trees and rocked. I lifted my face to the sun, peaking through the leaves, and smiled.

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Resting on the swing, early labor

My baby was coming today!

We called the midwife to share the news.

Around lunch time I decided I needed Appenzeller cheese. Paul understood my relentless cravings, having spent many afternoons wandering around the streets of Poland in search of mint chocolate chip ice-cream during my first pregnancy. He headed out to see what he could find, hoping that the gourmet deli that had recently relocated to our little town might have something close enough.

I sat on the deck in the same spot where I’d spent countless days of bedrest earlier in my pregnancy reading and watching wildlife and not at all missing work. I listened to the stream trickle nearby. A soft breeze rustled in the trees bringing with it the smell of early fall, of damp leaves. Birds sang in the trees. I closed my eyes and rocked gently in my chair.

Suddenly, somewhere deep inside I felt a small pop.

My breath caught in my throat as warm liquid trickled onto the deck. I realized with horror that my water broke, not something I had experienced spontaneously with either of my two previous pregnancies. I felt a fluttering in my chest as the contractions immediately intensified. I was alone at my house in the woods, my labor progressing with each passing minute. Why had I sent Paul away for cheese?

Before I had a chance to become fully panicked, though, I heard car wheels crunching up the driveway. In a minute, my savior was bounding up the stairs, a huge grin on his face, Appenzeller cheese in hand.

He stopped short when he saw my expression, then rushed over. “What’s wrong, sweetie?”

I was so happy to see him that I couldn’t find any words. He looked down at the puddle under my seat as another contraction gripped my belly. “Let’s get you to the hot tub!” he said, with a confidence that instantly made everything alright.

He set down our lunch and helped me up and over to the small portable hot tub perched on the edge of our deck. With much awkwardness, I heaved my enormous bulk over the side and slid into the water. Almost immediately, my body relaxed, and the pain of the contractions eased.

“How about that sandwich?” I asked Paul as I settled into the warm water. He let out his breath and smiled. “Coming right up!”

I got through most of that delicious sandwich, truly one of the best I ever had, before the contractions intensified again and I could no longer eat.

Paul sat beside the hot tub, holding my hand, whispering encouragement as each contraction passed. I hoped the midwife was close, but was afraid to say anything. “Do you think you should get out?” Paul asked, knowing I had no intention of delivering our baby in the hot tub. I shook my head furiously. I was afraid to leave the warmth of the tub.

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Active Labor

Paul slid the spare mattress out the door and leaned it up against the house “just in case”. When I had told our midwife that I wanted to spend part of the labor in my hot tub she insisted we have a mattress nearby. I though it was overkill at the time, but eyed it gratefully now.

“Hello?!” our midwife called rushing across the back deck toward us. One look at my face was enough. Years of caring for laboring woman provided instantaneous assessment. She didn’t need to examine me. “It’s time to get out of the tub,” she said gently. I protested weakly. “Unless you want to have the baby in there,” she added. I groaned. Paul and the midwife hoisted me out and toweled me off as I lurched through the sliding door toward my bed. It was not graceful.

The midwife introduced her smiling young assistant, Becky to us. I was very pregnant, dripping wet and naked but she didn’t seem to notice. I liked her right away.

Before we even moved in to our home, my husband got permission from the seller to cut down 2 birch trees from the property to make our bed. From the solid trunks he made four posts and from the smaller branches, he fashioned a head and foot board. It was enormous, a king size masterpiece that stood high off the ground and easily held our small family with plenty of room for extended family and friends.

The bed was a symbol of our love for each other. When it came to wanting babies, we were very different. I had always wanted children and loved the idea of a big family. Paul was not so sure. He wanted to live in nature. I was not so sure about this idea. He captured this beautifully in a poem that hung over the bed that I now heaved my naked, dripping body onto.

Two birch fell on a cool spring morn.
One by a clearing, one deeper in.
Together now a bed they are.
And I, having cut them long ago,
Have forgotten which was which

On a bed of birch two lovers dream.
One of mountains one of children.
So distant once but here we are.
And I, having loved her for so long,
Have forgotten which was which.

And now, our third son was going to be born in this very bed, under these words of love.

The midwife eased me onto my back and climbed up on the big bed beside me. I was pushing now with each contraction but was not making any progress. The midwife knelt next to me and Becky stood nearby. Paul stood by my head, watching me closely for cues. He knew from my previous labors that I couldn’t control my reaction to his loving caresses. One minute, I’d want his hand on my head and the next I was pushing him away. He didn’t take it personally, and I loved him even more for this.

The baby was not moving. I started to feel a little panic. The midwife smiled down at me lovingly. She knew I watched her every expression closely, looking for signs that something wasn’t right.

She lifted my leg and bent my knee until it rested on my belly. She asked Paul to do the same with my other leg. My heart felt heavy in my chest. I knew instantly what this meant. McRobert’s Maneuver! My baby was stuck!

With his free hand, Paul stroked my cheek. He saw the fear in my eyes and bent over to kiss me. Grateful, I didn’t push him away.

I knew from delivering babies myself that the shoulder sometimes got stuck behind the pubic bone. This was considered an obstetrical emergency. Complications to the mother ranged from hemorrhage to uterine rupture. For the child, they could be worse – nerve damage, fractured bones, hypoxia or death.

I looked to the midwife’s face, which remained serene as she applied pressure to my belly. “If the baby doesn’t come with the next push, I’m going to have you roll over onto your knees,” she whispered softly, as if she was giving instructions on where I should park my car. I took in a deep breath of her calmness. If she wasn’t worried, I shouldn’t be either.

Just then the shoulder slipped out from where it was lodged deep in me. Orion’s head appeared. In one swift movement, the midwife removed the umbilical cord from around his neck as he slid out. She hoisted the slippery baby onto my belly so I could have a better look while she quickly inspected me for damage.  Paul cut the cord.

Orion was a dusky color. He was much too quiet and still for a baby just forced from the warm security of his mother into the cold, bright world. The midwife slid him off my chest and on to the bed next to me. I would have panicked if it weren’t for her smiling brown eyes and reassurance. “I’m just going to give him a little oxygen,” she told me. I had no idea that they brought oxygen, but was instantly reassured.

As Becky adjusted the tiny mask over his face, I reached over and lifted up his hand. It was heavy and still. When I let go, it flopped limply back to the bed without any resistance. I looked fearfully to the midwife again. She smiled, “He will be just fine,” she said. “Look, he’s pinking up already!” And he was.

Soon, my other boys came home from school, noisily bouncing into the silent room. My parents had arrived too, anxious to meet their newest grandchild. Once the excitement had faded and the house had settled down again I asked permission from my midwife to take a bath (something I knew would never be allowed in the hospital).

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Meeting their Baby Brother

Paul tucked Orion into the cradle that he had made for Digby five years earlier.  He slept peacefully, rocking in front of the glowing wood stove. When I emerged from the bath, clean and invigorated, Paul was serving dinner to the midwife and Becky on the deck. I kissed my slumbering baby on the head and joined them.

There has never been a more beautiful September day.

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Orion

No such thing as a Free Lunch

Drugs and Poppies

I ate my last free lunch this month, the inevitable result of years of planning on doing just that. I had just needed a little push.

But I get ahead of the story.

Sally’s blood pressure was very high. When I last saw her (just over 6 months ago) it was perfect. I remembered congratulating her efforts at that visit. “Your blood pressure is like a teenager’s!”

What had happened?

I entered the exam room and asked Sally how she was feeling. She admitted to headaches and more fatigue.

I suggested ordering some tests and doubling her blood pressure medication.

“No, please don’t,” she mumbled. “I can’t afford any more tests. And, anyway, I don’t need them.” I waited quietly for her to continue.

“I know why my blood pressure is high. I stopped taking my medication a few months ago. I also stopped my diabetes and cholesterol pills, “ she stammered. “I felt ok for the first month, but I haven’t felt good for a while now.” Her eyes brimmed with tears.

“Why did you stop taking your medicine?” I asked gently.

She brightened up a little as she told me that her husband Bill finally got a job. He’d been looking for almost a year. Unfortunately, his new job meant that they lost their Medicaid because they no longer qualified. The new insurance offered by his work had a high-deductible. “We have to pay $3000 each year before our insurance kicks in,” she said. “I just can’t afford my pills and I’m worried sick that Bill might have another heart attack if he stops his.”

What could I possibly say? I silently fumed. In most civilized countries Sally and Bill’s medications would be covered. They wouldn’t have to make impossible choices.

I handed her a tissue and patted her gently on the back. “We’ll figure something out,” I told her. I knew that Sally and Bill were hard-working, proud people. It had taken a lot to convince them to apply for Medicaid when Bill’s company closed and he lost his job last year.

In the past I would have offered her “samples” to get her through this tough time. Samples were drugs provided for free by pharmaceutical companies to doctors’ offices. This is not so much a philanthropic gesture on the part of these companies as it as a means to allow their drugs to be tried out by doctors with the hope that those doctors will then be inclined to prescribe them. A few years ago, my office had a closet-full of drugs to dispense to patients hard on their luck. We were just like a pharmacy, but free.

Recently, the hospital decided to prohibit samples. There were many reasons for this. Meticulous logs had to be maintained with pertinent patient information, drug names and doses, lot numbers and expiration dates. It was difficult to keep track of all the drugs going in and out of the closet. We were a busy office. I’m sure I wasn’t the only doctor that tore the lot numbers off the box and gave the samples to my patients with the intention of logging it all in later. At the end of the day, with piles of papers to sign and notes to dictate, it didn’t always happen.

While most patients were grateful for the short-term help, many patients took advantage of this system that essentially provided drugs without co-pays. I could hardly blame them.  Rarely, a particularly entitled patient called angrily demanding medicine, even yelling at the nurses when samples weren’t ready. “I called yesterday for my Viagra! What kind of office are you running?” one man shouted to a shocked nurse.

Nurses got tired of this system as they did most of the leg work when patients called requesting samples. They filled out the logs and brought them to the doctor to sign. They called patients to tell them when their drugs were ready. They even called the pharmaceutical representatives (“drug reps”) to request specific samples when needed – all crammed in between normal duties of caring for patients in the office.

Over time sample closet rules became even stricter. Doctors were required to physically hand samples with printed instructions directly to patients. This wasn’t a problem for patients who were being seen for an appointment, but became a challenge for the ones who phoned every month for their samples. Instead of running for a bathroom break between patients, I’d be called to hand a waiting patient their samples.

My nurse coordinated the hand-off as soon as she saw me enter my office. In a smooth delivery she retrieved the samples from the closet, called the patient from the waiting room and summoned me. I stepped out of my office, took the bag from her outstretched hand and placed it into the patient’s hand. Frequently, though, patients had “just a quick question” for me and I found myself in limbo in the hallway trying to listen while calculating when I might get my next chance to use the bathroom.

Although I felt bad for patients like Sally and Bill who needed short-term help, by the time the hospital decided to forbid drug samples, I have to admit, I was relieved. And the nurses were elated. It really wasn’t a very good system. Patients became dependent on newer and more expensive drugs (no companies sampled older, cheaper drugs). When these drug samples were no longer available (because the drug rep hadn’t made it to the office in a while to deliver them or the company stopped sampling a particular medication) many patients were without their drugs.

All of this would not be a problem if I could write for any drug I wanted. If samples ran out, I could just write a prescription. But I can’t just write a prescription for any drug I choose. Insurance companies compile lists of preferred drugs (“formularies”) that have lower copays for their clients, outlawing some drugs altogether. These lists change frequently as cheaper drugs are added and more expensive ones are removed. They also change as drug companies negotiate discounts and rebates with insurance companies to gain more favorable formulary placement.

Doctors (with the help of overworked nurses) fill out frustrating “prior authorization” forms or write letters for patients when a needed drug is no longer covered. Sometimes this works, but sometimes doctors are forced to change medications that patients have been taking for years.

It wasn’t always this complicated. When I first started practicing medicine, I did get to choose the medicine I felt was best for my patient. My professional judgment and knowledge of my patients was respected. I wrote a prescription and my patient took it to the pharmacy and it was filled.

Last week I wrote a prescription for liquid doxycycline for a child very ill with Lyme disease. It took the persistent parent countless phone calls to both her insurance company and her pharmacy just to understand the process of how she could help facilitate getting her child’s medicine. It took several calls from me to my nurse and a trip in to the office to fill out paperwork on my day off to ensure the medication would be dispensed. When it was finally approved, the copay was very high since it was not on the insurance’s preferred list.

I didn’t prescribe a fancy new drug. Doxycycline has been around a very long time. It wasn’t the child’s fault the pills were too big to swallow or that they didn’t come in an appropriate dose for his size, thereby requiring a liquid form for precise dosing.

What happened? How did the cost healthcare become so unaffordable for Americans? I don’t claim to have all the answers, but clearly part of it is the expense of drugs. I know it isn’t cheap to develop and test new drugs. But why are drugs so much cheaper in other countries?

Some of this cost lies in the expense of all of the middlemen between the drug company and the patient. Some of it is in the paper pushers hired by insurances to serve as roadblocks for cost containment. If the expense of receiving and processing all the individual requests by doctors for formulary exceptions alone was eliminated, healthcare costs could be channeled to actually take care of people’s health.

And some of the cost, alas, is the expense of marketing theses drugs to consumers and convincing doctors to prescribe them.

A few years before I began practicing medicine, doctors received gifts and even expensive trips from drug reps. By the time I graduated medical school, though, the gifts were reduced to pens and notepads advertising drugs. Now even these small trinkets are no longer allowed in my state, which is a good thing.

The one significant expense that has not yet been outlawed in my state is feeding doctors. And busy doctors are hungry and eager for an easy meal.

During my residency training, I was actually able to bring my husband with me to a “drug dinner” at a fancy restaurant for the small price of listening to short educational talk and hiring a babysitter. Paul and I were grateful for those cheap dates since we were too poor and exhausted to coordinate dinner out on our own. A free meal was motivating.

A few years ago the laws changed, prohibiting spouses from attending these dinners. I stopped going. Up until very recently, though, I still went to the drug-sponsored breakfasts and lunches delivered to my work. It was convenient, tasty and free. Not only did I not have to pack myself a lunch, but I often learned valuable information at these meals.

I worried, though, over reports that these sales pitches might actually influence prescribing practices. And as the cost of drugs skyrocketed and my patients struggled to afford them, I began to feel worse about my free meals. Was I indirectly contributing to the high cost of drugs?

For the last few years, I debated a lot about whether to attend lunches anymore. In my small practice, though, I was afraid that if I made a personal stand and stopped going that the drug reps would no longer bring food to my overworked staff. Although I was the target of their free meals, I didn’t feel like it was my place to choose for the entire office.

I don’t mean to vilify the drug reps, who are hard-working people often passionate about their drugs. They have not only taught me a lot over the years but they also have provided patient education materials and patient assistance programs to those who qualify. But in the highly competitive pharmaceutical market, pressures to sell drugs are great.

Recently, instead of educating me, many drug reps confronted me with statistics on the drugs I prescribed. “I know you prescribed our drug twice this month,” one said to me. How did he have access to my prescribing practices? I found it unnerving. Another asked (inevitably when my mouth was full of food), “Why wouldn’t you prescribe my drug?” And yet another, “How do you pick which drug to try first?” I began to get defensive. I didn’t enjoy being grilled about my prescribing practices during my lunch “break”.

Not long ago a drug rep casually told me how he and another rep I knew were vying for a bonus. They were so close, he told me. He just needed someone to write a few more prescriptions for his drug and he would win. Wink. Wink. Nudge. Nudge. Was he seriously asking me to prescribe his drug so he could win a prize? Maybe not, but it made me very uncomfortable.

Which brings me to my last free lunch.

I was far behind schedule after a “routine check up” had turned into a medical emergency. Despite serious medical symptoms, my patient had waited until his appointment (“I knew I was going to see you in a few days”) to be seen. He couldn’t afford the extra copay for an additional office visit. For the past week, Robert experienced shortness of breath so severe that he couldn’t walk more than a few feet without becoming light headed. I suspected a blood clot in his lungs, which was later confirmed when he reached the ER.

After the rescue squad whisked my patient away, I rushed breathlessly to lunch, apologizing to the drug rep that I had to eat-and-run to be ready for my full schedule of afternoon patients.

I sat down with my plate full of food, shoveling in mouthfuls as the drug rep flipped through brochures in front of me that explained why his drug was superior to the rest. I nodded, glancing frequently at the clock behind his head. I answered his probing questions politely between mouthfuls. In record time (I had become very proficient in speed eating during residency) I finished my food and pushed my chair back.

The rep took no notice and kept talking. He opened up his computer to flash me more data. My feet rapidly tapped the floor under the table, willing me to run to my office so I could at least finish one dictation from my crazy morning before the next round of patients. I pushed my chair back a little further. I tried to be polite. I knew some of his show was for his manager, sitting across the table from me.

When he still ignored my not-so-subtle body language, I waited for him to take a breath and said, “I’m really sorry, but I had an emergency this morning and am very far behind so I have to get going,” I stood up.

I took a few steps away from the table. He leapt up and blocked my path. He actually stood between me and the exit from the lunch room. “Let me just show you this one other drug real quick,” he said. Before I had a chance to refuse he had opened a new brochure and began pointing to pie charts and graphs.

I was speechless. There was no escape. He rattled on. I resented him for forcing me to be rude, but I finally had to interrupt him. “Thank you again for a delicious lunch, but I really have to go now.” Before he could stop me again, I stepped around him and darted out the room.

I admit I felt some relief. Finally, someone had pushed me to the decision I had been mulling over for years. I was done with drug sponsored lunches.

I know my decision alone will not directly impact the high cost of drugs, but at least when I commiserate with Sally about the outrageous expense of medications I won’t feel like I am part of the problem.

After all, there is no such thing as a free lunch.